This is an application for a career development award designed to help the candidate gain knowledge and skills in health services and patient safety research, with an emphasis upon the delivery of out-of-hospital (OOH) Emergency Medical Services (EMS) care. The training component of this plan includes formal didactic coursework in health services research (HSR) as well as attendance at national HSR seminars and conferences. The candidate will participate in HSR seminars held by the Center for Research in Health Care, a highly active HSR collaborative based at the University of Pittsburgh. Patient safety training will be acquired through a formal didactic program organized by the Pittsburgh Regional Healthcare Initiative (PRHI), interaction with PRHI's ongoing region-wide patient safety initiatives, and participation in national seminars and conferences in patient safety. The sponsors will supplement didactic training with independent study assignments in the areas of HSR, health economics and biostatistical methods related to these areas. The proposed research project is an effort to identify the patterns and effects of errors occurring in out-of-hospital endotracheal intubation (OOH-ETI) performed by paramedics. Support of airway, breathing and circulation is the central theme of the resuscitation of the critically ill, and airway management is considered the most important intervention in this concept. ETI is considered the standard-of-care for airway management in both the in-hospital and out-of-hospital settings. OOH-ETI is a difficult error-prone procedure because of its underlying system complexity and dependence on preconditions. Pilot studies suggest that ETI performed by pre-hospital personnel is subject to a high incidence of error, including failure to accomplish OOH-ETI, multiple OOH-ETI attempts, or endotracheal tube misplacement or dislodgement. In the first stage of this study, the candidate will examine whether variations in EMS system structure, population setting, socioeconomic status, or patient racial and ethnic background are associated with the incidence of OOH-ETI errors. In the second phase, he will determine whether OOH-ETI errors affect patient outcomes or in-hospital resource utilization. These analyses are innovative in the fields of EMS, patient safety and health services research and will help to justify system-wide efforts to reduce errors in this complex procedure.